Provider Demographics
NPI:1366768046
Name:PETER J MARTIN
Entity type:Organization
Organization Name:PETER J MARTIN
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:509-284-2423
Mailing Address - Street 1:PO BOX 629
Mailing Address - Street 2:
Mailing Address - City:TEKOA
Mailing Address - State:WA
Mailing Address - Zip Code:99033-0629
Mailing Address - Country:US
Mailing Address - Phone:509-284-2423
Mailing Address - Fax:509-284-3434
Practice Address - Street 1:N. 115 CROSBY ST.
Practice Address - Street 2:
Practice Address - City:TEKOA
Practice Address - State:WA
Practice Address - Zip Code:99033-0629
Practice Address - Country:US
Practice Address - Phone:509-284-2423
Practice Address - Fax:509-284-3434
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty